Failure to Address Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to address and implement care plan interventions for a resident who experienced significant, ongoing weight loss. Despite the facility's policy requiring physician notification and care plan updates for significant weight changes, the resident's care plan did not address the weight loss. The resident's weight decreased from 196 lbs to 171 lbs over approximately six months, representing a 12.76% loss. The registered dietician documented the weight loss and noted that the resident's diet was regular, with variable meal intake, and that the weight loss could be related to fluid shifts due to diuretic use and a diagnosis of congestive heart failure. However, the only recommendations made were to continue the current diet and monitor weight, with no new interventions implemented. The resident reported feeling depressed and not eating much, but this decrease in appetite and mood was not identified or addressed by the facility until it was brought to the attention of the Director of Nursing, who confirmed being unaware of these issues. The facility's weight monitoring system did not trigger an alert for significant weight loss, and there was no documentation of physician or family notification, nor any evidence of care plan updates or new interventions to address the resident's ongoing weight loss.